The Endo Fix

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Resorption Classification for Clinicians

Deep Fix, Resorption

Historically, classifying systems for resorption have been insufficient to adaquitely guide the treating doctor and inform decision making in the clinical management of resorption . Words like inflammatory and replacement as identifiers are less than ideal as all resorption is inflammatory and all resorption involves replacement.  Identifiers using cervical when used to describe ECIR are not really accurate either and are really misleading as the resorption typically stems from the level of the crestal bone. For these reasons, based on more current models, I use a clinical model of classifying resorption, and subsequent management thereof:

Hampton Endodontist, www.endovirginia.com

The initial identifiers are based first on the derived process location- either external or internal. It’s important to note that the identifiers are derived from imaging, most often CBCT imaging.

Internal Resorption is derived from the pulp. The presentation can be with either a vital or necrotic pulp. Additionally, the resorption can be further classified by extent- namely non-perforating, or perforating. Internal Resorption that is perforating may require surgery to adequately manage the case. Often the process involves a vital pulp, however, occasionally, the pulp may be non-vital. From a prevalence perspective, internal resorption is low; its rare. With internal resorption, since the process is pulpally derived, the replaced tissue is radiolucent. There is not a bone deposition component to internal resorption.

Internal resorption with a necrotic pulp:

Suffolk Endodontist

Internal Resorption with Perforation:

Tidewater Endodontist

External resorption refers to the process of tooth structure being removed and replaced from the outside. Additional identifiers depict distinctions based on a mix of location, cause, and extent. External Crestal Resorption is by far the most common type of resorption. It originates at the level of the crestal bone. A mix of soft granulomatous tissue and hard boney tissue invade and replace the tooth. Additional identifiers include scooping or tunneling. Scooping refers to the pattern of extension by which it progresses in a relatively bowled out fashion as if the tooth removal was performed with a small ice cream scoop. Tunneling refers to a thin fingerlike progression, often many of them progressing axially. Finally, the extent of the External Crestal Resorption may be described. Mild refers to external resorption that doesn’t involve the pulpal space. Moderate is likely to involve the pulp space and will require endodontic therapy. Severe resorption is the extent whereby the tooth is usually no longer restorable. The determination of restorability is made via CBCT. One thing to keep in mind when determining the extent of the resorption is the hard tissue component invading the tooth. It’s easy to mistake tooth schema for invading bone or bone schema. Additionally, the pdl is not present in this area making the distinction more difficult. Sometimes, changing the scale of the imaging during viewing can help. that’s because the process of interpreting schemata is itself dependent on scale. For example, we understand that mouth is part of face, and lips are part of mouth, and vermilian border part of lips. Changing the scale helps with understanding features at all levels.

External Crestal Resorption, Moderate Scooping:

Suffolk Endodontist

External Crestal Resorption, Severe, Tunneling:

Tunneling Resorption presents challenges as the osseous tissue embeds itself axially. Aggressive removal weakens the tooth, however, leaving bone behind allows for resorptive progression.

External Apical Resorption:

Chesapeake Endodontist

External Apical Resorption can be a result of orthodontic force, root canal infection, or in some cases, unknown causal relation.

 

 

External Pressure Resorption:

Chesapeake Endodontist

Teeth and expansile growths such as cysts can cause pressure resorption. Depending on the restorability the extent may be mild, moderate, or severe.

External Axial Resorption:

Hampton Roads Endodontics

External Axial Resorption is identifiable by the radiolucent areas adjacent to root structures. Often this is sequela of trauma and accompanied by an infected tooth. This resorption may be arrested by endodontic therapy and medication with calcium hydroxide. The extent of the injury and development of the tooth determines the prognosis. Often injuries to these teeth include avulsion, lateral luxation, intrusion or extrusion. Depending on the extent of External Axial Resorption, External Ankylotic Resorption may follow over time.

 

External Ankylotic Resorption:

Newport Bews Endodontist

External Ankylotic Resorption may follow after External Axial Resorption. The difference is the lack of radiolucent areas adjacent to the root. As with other external resorption where bone deposition is involved, distinguishing between root and bone schemas can be difficult. The appropriate interpretive response is increased uncertainty. In the developing adolescent, when facial development is not complete, the management of External Ankylotic Resorption is decoronation. An alternative might include autotransplantation if there is a knowledgeable and skilled surgeon.

 

 

Crown Repair

Weekly Fix

Chesapeake Endodontst

Hampton Roads Endodontist

Newport News Endodontist

Newport News Endodontst

Suffolk Endodontist

 

A quality crown repair is important for successful patient centered outcomes. What’s desired is a quality core and an esthetic closure. There are options in achieving these goals, and presented here is just one process. I’ll outline the steps, materials, and rationale. This case was a retreatment from a restorative failure; the core was poorly adapted and the tooth was symptomatic. The patient was highly motivated to prevent this mode of failure on the retreatment. Amalgam as a core has a long track record and because of it’s handling characteristics works will in very conservative accesses where pulp horns have been intentionally preserved.

  1. Chamber Cleanup: After obturation, I like to clean up the obturation interface with a peezo with that little bump cut off. Just zip it off with a football bur.  A #2 works well if your final file is around a Protaper F1 (22.07). If more conservative instrumentation is used, I find the #1 works well. Then alcohol to clean up any remaining sealer, followed by etch. That’s my chamber cleanup protocol.
  2. Bonded Amalgam: At this point you gotta decide if your going to bond your amalgam. The available evidence suggests there are likely benefits, so I do it. Clearfill primer, air dry, then Clearfill bonding agent which is light cured. A second unset bonding agent is placed and the amalgam is condensed into this second top layer of uncured bonding agent. The dual cure nature of this bonding agent creates the bonded amalgam.
  3. Carving the Amalgam: I like a spoon for this. If you want you can get some mechanical retention by undercutting the casting a little. Hard to say if it makes a difference. But I do it on Zirconium crowns.
  4. HF Etch: At this point make sure you have a good bevel using a course football bur. Then hydrofluoric acid is used to etch the porcelaine, this minute feels like forever. Then my assistant suctions the acid and she rinses while I scrub the precipitate off. If you don’t scrub it, the bond won’t be as good. I just use a piece of sponge. Then dry the water off.
  5. Silane: You can use an additive to the Clearfill Primer or just the silane. The silane has a long track record. Newer isn’t always better. The silane needs to be air thinned.
  6. Bonding: Then I place the Clearfill bonding agent over the porcelaine and amalgam.
  7. Opaquer: I like the permaflow flowable composite. It has an opaquer shade that hides the silver really well.
  8. Composite: We use Filtek body- it works well with Clearfill products. My assistant expresses part of a carpule on a mixing pad, then scoops up the composite on the back of a spoon. We use the orange filter so the composite doesn’t set, and apply the first bank of composite. After it’s manipulated in place and cured, we add a couple more increments using an endo explorer or a spoon to shape the composite.
  9. Finish and polish: Usually we don’t need much adjustment. But it’s important to get the occlusion right. A fine football and a zirc polishing point helps on any adjusted parts of the crown.

That’s it! Pretty and predictable.

 

 

Rethinking Retreatment

Deep Fix

Suffolk Endodontist

Hampton Roads Endodontist

 

A more traditional approach to retreatment thinking was given to me courtesy of Ken Serota with this first algorithm. The focus of the decision making is on the quality of the root filling. Decision making with such a matrix often results in retreatment without necessarily improving patient centered outcomes. The second algorithm is restorativley driven with the expressed interest in improving patient centered outcomes and meeting treatment planning objectives. The other pillars of restoratively driven endodontics are present as well including conservation of tooth structure, and determination of restorability based on remaining tooth structure.

Frustum Retention

Daily Fix

Keeping the preparation conservative even in the last 2-3 mm helps in retaining the core. The shape of the access here is a frustum, or pyramid with the tip cut off. This providees a macro-retentive feature for the core. Terminal teeth can be difficult to place a band on so we used a custom resin matrix.

Shaking My Head

Daily Fix

 

This is one of those cases that doesn’t make any sense. 7 years on a cracked tooth with probing to the apex… probings adjacent to the cracks. We put him in meds for a couple months, the probings resolved. Then we put a core in and let him sit for another 3-4 months. He came back for the other side yesterday, with a necrotic molar with probings. He’s weighing his options, but still, I’m not optimistic.

Deep Margin Management

Weekly Fix

hampton roads endodontist

Suffolk Endodontist

 

Deep caries and the resulting deep margins can be a restorative problem especially when the patient has a history of interproximal caries or a “high caries hostility index”. Generally speaking it’s better to have a crown that fits and fits on a meticulously placed deep restoration than a crown that doesn’t fit. And when the margin is very deep, then that is when a poorly prepared and poorly captured margin is most likely. An alternative is DME or deep margin elevation. Dentists have unintentionally placed margins on amalgam for decades with success. It’s likely that the outcomes will be even more favorable when done intentionally under controlled circumstances, under magnification and with no overhangs. Attached is a 7 year outcome with the crown placed on amalgam. Also attached are two very long term outcomes. When placing margins on restorative material, it is probably best to choose amalgam over composite as it does not rely on bonding which is poor under such conditions. It’s also advisable to evaluate the emergence profile of the tooth, it’s contact with adjacent teeth, and potential plunger cusps that led to the problem to begin with. Managing these variable can prevent food impaction and decrease the probability of failure to recurrent caries.

Dual Entry Molar

Daily Fix

Hampton Roads Endodontist, www.endovirginia.com

Hampton Roads Endodontist

 

Caries on the mesial and distal made this a dual caries leveraged access. We modified a UT4 to prepare under the truss. An old perio probe and shepard hook explorer was modified to be a plugger to adapt amalgam for the case.